Meet the Obturator Internus

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You all know by now that I’m fairly nerdy. I love reading research articles, trying to understand complex topics, and everything about learning. Honestly, I think that is why I love pelvic health so much! The pelvis is so complicated! There’s so much to know, and the more I learn, the more I truly realize how much more there is to know! As an anatomy nerd, you know I have favorite muscles. I’ve written about the respiratory diaphragm, who is one of my most favorites, but I haven’t spent much time introducing you to my other love~ the obturator internus!

Meet the Obturator Internus

The Obturator Internus (Or OI, as they are known by friends) is a muscle that lives inside your pelvis in the obturator foramen and attaches to the hip via the greater trochanter. You can see it here:

The OI has several major functions for the body. First, it is a deep hip external rotator, and has shown to be active during the movements of hip extension, external rotation and abduction. In fact, this research showed that it was the first muscle to turn on in these motions (which I theorize could be part of it’s connection to the pelvic floor muscles and the anticipatory role the pelvic floor has in movement, pressure management and postural stability). My theory on this makes sense when we look at some of the research on the involvement of the OI in hip stability. This excellent article identifies the obturator internus & externus, quadratus femoris, and gemelli as important synergistic muscles that work together to modulate the position of the femoral head in the acetabulum during movement. This is particularly cool because in many ways, this function is very similar to the pelvic floor muscles! The authors suggest a dynamic stabilizing role for these muscles, making subtle alterations in force to control the femoral head position.

This study also recognizes the stabilizing role the OI can play, particularly when it works as a team with the other deep hip rotators. The authors here highlight that the obturator internus, obturator externus, superior & inferior gemelli (who I affectionately call the gemelli brothers) are essentially fused. And this fusion, actually leads to a decent cross-sectional area and ability for force generation. The orientation of the fibers adds further credence to the view that these muscles are crucial to hip stability.

The OI shares fascial connections and attachments with the pelvic floor muscles, which makes it an even more unique muscle. The iliococcygeus attaches to the arcus tendoneus linea alba, a fascial line that is also an attachment of the obturator internus. Additionally, the pubococcygeus and OI are fascially connected around the pubic bone, and the fascia around the bladder and urethra also is connected to the OI. What does this mean? It means that the OI can be impacted by what happens at the pelvic floor and can impact what happens at the pelvic floor. And research tends to show this. This study showed that the vast majority of people with pelvic girdle pain have obturator internus tenderness. This study found that most people with chronic pelvic pain have obturator internus tenderness with palpation. And here’s another study that found that 45% of people with pelvic pain had tenderness at the obturator internus. Another study found that in people with lumbopelvic pain, experiencing urinary urgency, and central sensitization made them 2x more likely to have concurrent pelvic floor and OI involvement.

Finding the Obturator Internus

One of the cool things about the OI is that it is a muscle that can be palpated both internally via the vagina or rectum, and also externally. The OI is palpated internally with an examining finger angling out toward the hip. You can see the palpation here on my lovely pelvic model.

My finger here is inserted, curving toward the left to access the OI

The OI can also be palpated by examining medial to the ischial tuberosity, then angling in toward the obturator foramen. You can see where palpation would be happening here.

Treating the Obturator Internus

If you think your Obturator Internus is involved in the pain or pelvic floor problems you’re experiencing, the first step is to have it examined. Your PT can palpate these muscles as described above. The muscles should be soft and move well, so they should not be sensitive or painful to touch. If they are, they could potentially be involved in the pelvic problems you are experiencing.

From a treatment standpoint, we can address the OI by first improving the mobility via gentle manual therapy, and then improving the overall hip stability (retraining the anticipatory function through the relationship between the pelvic floor & OI). It usually isn’t the “sole” problem happening. But including it within your treatment can be key to helping you get better!

Cheers!

Jessica

LIVE Class Mon. 8/31: Easing Constipation

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Did you know that 1 in 5 people struggle with constipation?

Constipation is the #1 reason people seek a GI specialist. I write about pooping problems a lot. And for good reason– the bowels are something people often take for granted, until things aren’t working optimally.

The great news is that there is SO much you can do to help your bowel function! This Monday 8/31, Sara Reardon and I are teaching a LIVE 90-minute class on Easing Constipation!

In this class you’ll learn:

✅ What defines constipation and common contributing factors

✅ Pelvic floor muscle anatomy and how to use your muscles to help with defecation

✅ Dietary recommendations to help keep bowel movements soft

✅ Tips on managing constipation with prolapse (rectocele)

✅ Self-treatment techniques including building a bowel routine, optimal toileting posture, and breathing and relaxation exercises

✅ BONUS Handouts on abdominal massage for constipation, proper toileting mechanics to facilitate emptying and more!!

You won’t want to miss this class! Registration for the LIVE class is limited, and we think this class will fill quickly! So be sure to secure your spot soon, and get your questions answered! If you can’t make the LIVE class, register now and receive access to the recording & all bonus content within 24 hours after the event!

Register here!

Hope to see you there!

~ Jessica

Do you leak when you run? Try this!

August 11, 2020 ~ jesspreale ~ Leave a comment

I love running. To be honest, I’ve been out of a good running routine since Mary was born. She’s one now. I would like to change that. I’m scheduled (yes, my husband and I literally have to schedule everything with our crazy work weeks!) for a run this week and I’m thrilled.

As a pelvic physical therapist, my goal is always to help my support my patients in whatever exercise or fitness routine they enjoy. Sometimes, pelvic floor problems get in the way. I can’t tell you how many times I’ve heard things like: “I used to run all the time, but ever since I had a baby, I just can’t” or “I tried just wearing a pad while I was running, but I can’t get over the feeling that I’m making everything worse” or “I can run if I go first thing in the morning, empty my bladder before I leave, and then stop at the park on the way to go again.” Bladder leakage during running is ANNOYING. It can be so impacting to people, and for many, it can lead them to stop a movement or activity they enjoy, for the long-term.

5 years ago (has it really been that long!?!) I wrote on the topic, “Is running bad for the pelvic floor?” after receiving that question several times. Spoiler alert: There are times when it may be appropriate for someone to stop running for a period of time to retrain their body and regain their pressure modulating system optimization– however, running can be an excellent way for someone to exercise and move! There are no “Bad” exercises, just bodies that sometimes aren’t quite ready for them.

So, if you’re struggling with leaking every time you hit the pavement, what can you do?

Let’s consider what happens during running, from a pelvic floor standpoint. Several studies in the past few years have demonstrated that the pelvic floor muscles are active during running. This study from 2017 used EMG electrodes at the pelvic floor muscles, and found that there was increased activation of the pelvic floor prior to heel strike and reflexive activation after heel strike during running. This is in line with what we know about the pelvic floor muscles. They play a crucial role in anticipating movement, preactivating, then have modulating force during movement based on the task at hand. And, this is protective. We would want the muscles to have varying levels of activation so that we can support ourselves during movement, support around the urethra, not leak.

What happens then when someone is leaking with running? We of course, want to say that this reflexive thing is not happening. This review did show some alterations in the way that those who leak contract vs. those who do not leak. However, this study found that the reflexive action was the same in those who leaked and those who didn’t. This one also found that patterns of engagement were the same. So, it is likely that there are sometimes differences, but sometimes not. And this seems in line with what we know about leaking. Leaking during running is a pressure system problem. So, to help it improve, we have to address the whole system– which includes the pelvic floor muscles, but not only the pelvic floor muscles. It makes sense that sometimes the issue is stemming from these muscles not activating at the right time, with the right force–but sometimes, the pressure problem is from something else.

How can we address the pressure modulation system?

First, we need to evaluate the system to see how the structures are functioning, and this includes looking at you– the full person– to see how you control pressure through your pelvis. So, we need to look at how you move from head to toe, then evaluate your running mechanics, then look more closely at your breathing pattern, your abdominal wall, and your pelvic floor muscles. Once we do this, we often have a clear idea of what is happening and can make a strategy to get this better.

So, my big Tip #1– Go see a pelvic floor PT–but make sure it’s someone who is trained at looking at the whole person and can really evaluate you well.

If you’re nervous about doing this, I feel you. It can be hard to talk to someone about very private things. And I totally understand that the idea of having an internal examination can be a barrier for some people. BUT, know that those of us living in the pelvic floor world talk about this stuff ALL THE TIME. You won’t surprise us. Seriously, we hear this stuff all day. And, if you don’t think you’re ready for an internal exam, that’s cool. Honestly, we don’t mind. There is SO much that can be done to help the pelvic floor and bladder leaks that can be done without an internal exam! If you want to learn more, give us a call. One of our doctors of physical therapy will be happy to do a virtual consult with you and get you started!

Ok, off my soap box… What else can you do to impact the pressure modulation system and decrease leakage?

Tip #2: Breathe!

This seems so simple. I know, you’re thinking, “Of course I’m breathing!” But, are you? Or are you going through a series of breath holds? Next time you run, pay attention, and keep your breath flowing in and out as you run. The diaphragm is the major pressure regulator of the body. So, we need to keep your breath moving so pressure is spread out!

Tip #3: Let your ribcage move!

Many people tend to run with stiffness, locking down their ribcage. This can funnel pressure downward toward the pelvic floor muscles leading to increased load, and potential leaking. Instead, relax your ribcage, let your arms swing and allow your trunk to rotate. This will actually turn on more of the muscles around your core improving the synergistic activation of your pressure modulating system.

Tip #4: Lean into the hills!

When going up or down hills, it is easy to lean back to try to control the movement. This can alter the position of your ribcage over your pelvis which will impact your pressure control. Instead of doing this, lean into the hill as if you have a strong wind blowing against you (I love this visual I got from my friend & colleague, Julie Wiebe!). When going downhill, lean into the downhill and let yourself pick up a little speed instead of leaning back to slow down. Relax into the hill. Many of my patients find that doing this actually reduces the pressure they feel and can decrease leakage.

Tip #5: Get a running evaluation!

Running form matters, it really does! So, go see someone and have them take a look at your running form to offer you guidance on how you can optimize it! Be sure you’re using the best type of shoes for your foot as well! This can make a big difference! Awesome running stores in your area should be able to help you with this!

I hope this is helpful! What questions do you have about running and the pelvic floor? Ask away! We are here to help!

Have a great week!

~ Jessica

Clinical Expert Interview on Fecal Incontinence with Dr. Swetha Ramakrishnan

July 21, 2020 ~ jesspreale ~ Leave a comment

Good morning everyone!

This past week, I was so fortunate to sit down with Dr. Swetha Ramakrishnan to discuss fecal incontinence. Fecal incontinence is a MAJOR problem, impacting 7-15% of people. It is the #2 most common reason people are admitted to nursing facilities (guess what? #1 is urinary incontinence!) and it can happen in young and old alike. In fact, anal sphincter injuries are a common occurrence during vaginal birth (occurring in around 10% of vaginal births worldwide) and 9-24% of those people go on to develop anal incontinence.

At SPH, we use a multi-faceted approach to help people with bowel leakage which includes helping to optimize their stool consistency, facilitating a strong bowel routine, retraining digestive reflexes and encouraging functional pelvic floor muscle function (which does include that anal spinchters).

I’ve been treating colorectal conditions for over 10 years, and Dr. Rama and I have worked together for the past 5 years. She is an incredibly skilled, intelligent and kind provider with ATL Colorectal in the metro Atlanta area. I hope you enjoy our discussion on bowel leakage– what it is, why it happens, and the very important, what you can do about it!

If you have any questions, drop them in the comments below!

~Jessica

“Just the normal incontinence” and other common myths about pregnancy, birth, and beyond

June 29, 2020June 29, 2020 ~ jesspreale ~ Leave a comment

At Southern Pelvic Health, we offer free 15-minute phone consultations for people to determine if pelvic floor physical therapy is the best next step in their health journeys. These consultations are awesome– they give us a chance to get to know the patient, give the patient a chance to ask any questions, and help us start building a partnership if physical therapy care ends up being their next step. For some, it is. And for others, it’s not. Sometimes we refer patients to their physicians or other specialists. Sometimes, we encourage them to wait before coming in for a procedure, surgery, or something else.

Recently, I spoke with a new mom experiencing some difficulties that happened after birth. As we were talking, I asked her if she was having any bladder leakage, or other bladder challenges. She said, “During pregnancy, I had the normal incontinence, and I do leak some now, but nothing unusual.” Let that sink in. Why is bladder leakage, ever, looked at as a normal thing? Spoiler alert: It’s actually not normal. And guess what? There is something you can do to help it. Even during pregnancy.

So, this inspired me to write a post on some of the common pelvic health myths around having babies.

Myth #1: Bladder leakage is normal during pregnancy or after you’ve had a baby.

I already spoiled this one. It’s actually not. Common, yes. But not normal. During pregnancy, people can be more susceptible to leakage at certain times as the growing uterus changes the angle of the urethra, but the body should still be able to compensate, support the urethra, and avoid leakage. After having a baby, it can be normal to have some leakage in the first few weeks (depending on your birth), but then, it should improve. Continuing to leak after that initial healing period is actually not normal, and there is so much that can be done to improve this!

Myth #2: If someone is experiencing prolapse after having a baby they will eventually need surgery.

I hear this one a lot. Comments from well-meaning providers saying things like, “we’ll need to fix that when you’re done having kids.” So, let’s dispell a few myths. First, prolapse is SO common. Some studies have shown that up to 90% of people have some level of prolapse after birth (when checked on examination). This, of course, is going to be a much lower number when you look at people also having symptoms of prolapse. Prolapse is a pressure management problem impacting organ and tissue support. Organs and tissues are supported in the pelvis by fascia, ligaments, connective tissue and muscle. While we can’t necessarily change prior tissue damage via rehabilitation efforts, we can optimize muscles to improve the pressure system. And there is evidence that this reduces the stage of prolapse and improves the symptoms too! Additionally, there are other conservative options to help manage prolapse as well. Pessaries are wonderful support devices that can be used, and most people found them to be very helpful when we look at the research.

Myth #3: After having a baby, it’s normal for sex to be a little uncomfortable.

Pain is the body’s alarm system, produced by the brain to protect us. Pain is meant to evoke action on our part– to get us to protect the body, do something, to stop the “threat” from occurring. Sexual intimacy is meant to be pleasurable–before and after having a baby. Upon first returning to sex after birth, it can be normal to have a little bit of discomfort, HOWEVER, this should very quickly go away. If it persists, that’s a problem, and (you guessed it!), there is SO much we can do to make this better! Why does pain happen after birth? It can be a lot of reasons: scar tissue inhibiting the movement around the vaginal opening, decreased lubrication due to hormonal changes, musculoskeletal restrictions due to injury or dysfunction, and others! Read more on sex after baby here!

Myth #4: Low back or pelvic pain during pregnancy is just part of it.

Let me say it a bit louder for the people in the back: COMMON DOES NOT EQUAL NORMAL. Low back and pelvic girdle pain are indeed common during pregnancy, impacting anywhere from 4-84% (don’t you love those huge ranges we get in research) of pregnant individuals. While many cases resolve after birth, some people will continue to experience problems. Also, who wants to struggle with back and pelvic pain for months on end while they are pregnant? Not me, and I’m guessing not you. So, there is a lot that can be done to help this during pregnancy. Not surprising, research is mixed on the effectiveness of various techniques, and honestly, I think that is because treatment really needs to be individualized. Some tout “stabilization exercises” however, some studies have shown that most people with pelvic girdle pain actually have pelvic floor muscle overactivity— so of course, transverse abdominis and pelvic floor strengthening is going to make them feel worse! Key concept here- if you are pregnant and experiencing back or pelvic pain, go see someone who has specialized training in perinatal and pelvic floor care who can assess YOU (individually– not making assumptions!) and help make a plan to get you feeling better.

Myth #5: There’s nothing you can do about constipation during pregnancy.

Constipation during pregnancy is the worst! We can thank hormonal changes for that. While there’s not much we can do to change the hormones (nor would we want to!), we can do everything else to optimize our bowel habits and promote better bowel health. This includes learning the best way to sit on the toilet, proper mechanics for defecation, how to build a stellar bowel routine, and making dietary changes to promote better bowel function.

Myth #6: Do your Kegels, mama!

Surprisingly, this is actually false. While all pregnant individuals were told in the past to do kegel exercises to protect their pelvic floor muscles and optimize their births, we know now that not everyone actually needs pelvic floor strengthening. Remember, a large percentage of people actually struggle with pelvic floor tenderness and overactivity— especially if they are experiencing back/pelvic pain, or have pre-exisiting pelvic floor disorders. So, the best way to optimize pelvic floor function during pregnancy? Go get an exam, and have a skilled, specialist trained clinician help you get an individualized program for your pelvic floor.

Myth #7: There’s nothing you can do to really prepare your body for birth or prevent problems after.

Actually, there is emerging evidence that suggests we can do something to prevent problems like urinary incontinence, and other pelvic floor disorders. A recent Cochrane review (this is basically, the highest level of evidence we have) indicated that a targeted pelvic floor training program early in pregnancy actually decreased the risk of urinary incontinence during and after pregnancy. Exercise during pregnancy has also been shown to be safe and beneficial for the baby. Perineal massage has also been shown to be helpful in improving pelvic floor mobility and reducing perineal trauma during birth (particularly, during the first vaginal birth!). Want more info on preparing for birth? Check out our class on the topic!

Myth #8: The only way to change your belly problems after having a baby is with surgery.

If you’ve been following this blog, you’ve probably read our recent 2-part series on diastasis rectus after birth (If not, check out part 1 & part 2!) Many people experience diastasis rectus during pregnancy and after birth, or may just feel laxity and a loss of support at their belly. Rehabilitation of the abdominal wall can be so hugely beneficial for these people (myself included– hello cesarean birth x 2!). Surgery can sometimes be an option, but really, this should be used after a person has exhausted conservative options. So, if you’re struggling with belly problems after birth, give us a call! Check out our DRA class in the meantime also!

Myth #9: You can jump right back in to whatever exercise you want after having a baby.

I guess technically this one is true. You can do anything you want. But, that doesn’t mean it’s a good idea. Having a baby can be very impacting to the abdomen and the pelvic floor muscles, and it’s best to build back up to desired exercises slowly and methodically. I always say I would much rather someone wait and slowly get back to exercise than to jump into strenuous exercise too quickly. I can’t tell you the number of patients I have seen who have had problems like pelvic organ prolapse, or other pelvic floor conditions after resuming really high intensity exercise without adequately preparing their bodies. I don’t tell you this to scare you– believe me, I want you to get back to EVERYTHING. I want you to be a strong mama who can rock exercise EVEN BETTER than you did before your birth. BUT, I think we need to be smart about it, ease into it, and learn how to self-asses our bodies to make sure we do the exercises that are most appropriate for us at the time.

Myth #10: Moms don’t need to see a pelvic PT if they don’t have problems after birth.

Did you all know the pelvic floor physiotherapy is actually the norm after birth in some European countries? And why shouldn’t it be? Birth is transformative and hugely impacting to the body! Why is rehab after an orthopedic surgery nearly required, yet moms are not even offered rehab after cesarean births or operative vaginal births? In my perfect world, I would love to see all parents given the opportunity to seek pelvic health care after birthing a baby. In fact, wanna know a little secret? I’m actually seeing my colleague (Dr. Kate Schenk, who is a rockstar!) for pelvic floor and abdominal wall rehab this week! You may be thinking, didn’t you have your baby a year ago, Jessica? Good point my friend. But, like many other moms, I decided to put myself on the back burner for a while…and a while turned into a few months…which then turned into a year. When we celebrated my little Mary Lynn a few weeks ago, I had a moment of, “what am I doing?!” and quickly contacted Kate to make my first appointment! I’ll write on my journey later, you can be assured of that. But, don’t be me. Put yourself first. I know it’s hard (believe me!) but self-care is actually not selfish, it’s self-less! (And reading my post on self-care from 3 years ago, I realize that this has clearly always been a struggle for me!) Recently, we actually took a close look at the ways we are caring for our pregnant and postpartum patients, and realized, we can do better! So, we started offering in-home prenatal and postpartum care! I am SO excited about this– to be able to reach people where they are, reduce their (and their baby’s) exposure to…ummm… “germs” in the community, and take away some of the stress of getting childcare to get out of the house!

What else have you heard is “normal” for people during pregnancy and after birth? I know I didn’t hit all of the common myths out there! Let me know in the comments, and let’s keep the conversation going!

Happy Monday!

~ Jessica

Re-thinking rehab for incontinence after prostate removal

June 16, 2020 ~ jesspreale ~ 2 Comments

This week is international men’s health week, so it seemed fitting to write on a topic related to pelvic health in men. Interestingly enough, men are actually an underserved population when it comes to pelvic health. I know, shocking, but it’s true. From a physical therapy standpoint there are way fewer clinicians who treat men than there are who specialize in women’s health or prenatal/postpartum populations. In fact, I can’t tell you the number of men I’ve seen in the clinic who tell me that they were turned away from multiple previous clinics or who saw another provider who clearly felt uncomfortable treating them.

For me, I knew when I started specializing in pelvic health over 10 years ago, that I wanted to treat ALL people. I never limited my training to vaginas, and I always tried to learn to serve everyone. When I opened Southern Pelvic Health last year, I wanted to build a clinic that could really serve ALL people. We treat anyone who comes in the door, and our clinicians and staff constantly strive to be educated to provide a safe and welcoming space for anyone we meet.

So, this brings us to Men’s Health week! Today, I want to talk a little bit about rehabilitation after prostate removal surgery– aka prostatectomy. Prostatectomies are most often performed when a person has prostate cancer, and involve removal of the prostate and the portion of the urethra that runs through the prostate. This is most often done robotically currently. Prostate removal surgeries can have some side effects, and one of the most annoying side effects is stress urinary incontinence. Sexual dysfunction is also a major side effect, and of note, these two side effects are ones that many express feeling unprepared for. These two can have a huge impact on quality of life of many individuals after surgery.

Why does incontinence happen after prostatectomy?

The prostate sits under the bladder, and thus, plays an important role in continence. There is an internal sphincter that is present at the level of the prostate right at the bladder neck, as well as an external urethral sphincter below the prostate, which is part of the pelvic floor muscles. When the prostate is removed, the support and sphincteric control at the bladder neck is impacted. Additionally, the external sphincter can be damaged with the surgery, and patients can also have damage to neurovascular structures, fascia and connective tissue and the urethra itself. This then leads to bladder leakage– most often termed as “stress incontinence” which is leakage occurring with an increase in intraabdominal pressure.

The majority of individuals will have some degree of bladder leakage immediately after the catheter is removed. When looking further down the line, numbers are actually hard to estimate as different authors and surgeons have different ways of defining and measuring leakage. One study found that at 3 months post-prostatectomy 35% had bladder leakage. Another study found that leakage lasting more than a year happened in 11-69% of individuals. Yes, those are vastly different numbers.

How can it be treated?

As I mentioned above, leakage after prostate surgery can be so impacting for patients! And many feel guilty for being bothered by it… it’s the whole, “At least I don’t have cancer anymore…” guilt. But, here’s the thing. Quality of life matters. Yes, not having cancer is HUGE, but YOU matter. Your life matters. And helping you live your best life? Well, that really matters a lot. So, if you’re reading this and feeling frustrated about your bladder problems after surgery (or any other problems for that matter!)– I see you. There’s hope and help available!

Retraining the external urethral sphincter an be helpful for some people after prostate removal, and that’s where we pelvic floor physical therapists come in. The key thing here is optimizing the muscle system, which involves retraining the pelvic floor muscles to help them be able to contract well, relax well, and coordinate. I remember working with a urologist previously who told all patients after prostatectomy to do 10 second pelvic floor contraction holds, 10 times, every hour of the day. And guess what? When I saw most of his patients, they had significant challenges with pelvic floor muscle overactivity, and some even had pelvic pain. Why? Because it was wayyyy more than THEIR pelvic floor muscles needed. The best treatment is the individualized treatment! So, if someone has pelvic floor muscle overactivity, the best treatment is the one focusing on relaxing/lengthening the pelvic floor muscles. If someone has underactivity, the goal should be in regaining strength, endurance and building control. And if a person struggles with coordination, the goal should be retraining timing and control of the pelvic floor muscles.

Research has always focused on strengthening the pelvic floor muscles, and honestly, I think this is one of the reasons we see mixed results in studies. It makes sense, and it really is what I tend to see in the clinic. I was so pleased to see this study come out a few months ago looking at an individualized pelvic floor rehab approach for patients after prostatectomy. In this study, they reviewed 136 patients who had leakage after prostatectomies, and they found that 98 of them actually had muscle overactivity with underactivity. Guess what? Only 13 had underactivity with no tension/overactivity. This is honestly what I tend to see the most clinically. In this study, they individualized treatment based on the examination findings, and they found that 89% of the patients had a reduction in their urinary leakage. 58% achieved what was deemed “optimal” improvements in their leakage. This is good news, and really highlights the benefit of having a comprehensive examination and treatment (not just going somewhere for “biofeedback training”)

When a person is ready for strengthening (generally, after overactivity has been improved), the way strengthening happens actually matters. In fact, it really, really matters. Paul Hodges has done amazing research to help us better understand the continence system in men. In short, the system is different, and requires a different approach to rehabilitation. When the prostate is removed and the loss of the internal sphincter occurs, compensation must take place, and involves the external urethral sphincter, and can also include other muscles (particularly puborectalis and bulbocavernosus). So, it is very important for a clinician to evaluate the entirety of the pelvic floor muscles and not simply focus on the muscles around the anal canal. Hodges has multiple recommendations for how to be as precise as possible with pelvic floor rehabilitation, and you can read more about what he recommends here. After the right coordination, and activation of the pelvic floor muscles happens, it is so important to integrate these muscles into function. A robust home program that integrates the pelvic floor muscles into movement is key to helping a person regain bladder control!

I hope you found this information useful. I have a lot more to say about all of this, but it’s late, and those thoughts will have to wait for another day! Let me know any questions you have in the comments!

~ Jessica

Daily Movement Sequence for Pelvic Pain

Happy baby pose with knees up and open, supporting legs with hands

May 28, 2020June 4, 2020 ~ jesspreale ~ Leave a comment

May is Pelvic Pain Awareness Month, so I thought it was only fitting to write something about pelvic pain before the month is over. Pelvic pain impacts so many people, in fact, the International Pelvic Pain Society estimates that over 25 million women suffer from chronic pelvic pain. While the number is generally lower in men, some studies estimate that around 1 in 10 men experience chronic pelvic pain (often termed chronic prostatitis).

Next week, my clinic is officially re-opening our doors for in-person sessions, after operating completely virtually for the past 2.5 months! During this time, I tried to stay as connected to our patients as I could, and sent out a newsletter each week full of pelvic health tidbits. One of the new things I created was a daily movement sequence for pelvic pain, and I wanted to share it with all of you here!

Getting Started

Before we get started, you should know a few things about pelvic pain. First, each person with pelvic pain is a unique entity. So, while this sequence can feel lovely for many people with pelvic pain, some may not be quite ready for it. For others, they may find that doing it actually increases their pain (clearly, not our goal). For rehabilitation for a person with pelvic pain, it is very important that exercises, movements and activities are done at a threshold that does not increase or aggravate pain or discomfort. This is, as we have spoken about very often, because we want to create positive movement neurotags for the brain. Basically, we don’t want your brain to think that movement is bad or dangerous (because as we all know, it should not be bad or dangerous!). If we do movements that increase our discomfort and make us feel worse, the brain can build a connection between moving that way and bad/pain feelings. Instead, we like to move at a threshold where the body does not guard or protect by pain. So, why am I telling you this? Because, if you start doing these movements and your symptoms worsen, or it doesn’t feel therapeutic to you, you need to stop doing it and see a pelvic floor therapist who can evaluate you comprehensively and help you develop a specific movement plan that IS therapeutic to YOU. And lastly, remember that anything on this blog is not in any way a replacement of in-person care. You need to consult with your interdisciplinary team (your physician, PT, etc!) to determine the best approach for your health! (And if you’re not sure, schedule a virtual consult with a member of my team to help figure out where to go next!)

Daily Movement Sequence for Pelvic Pain

So, let’s break down this sequence.

Diaphragmatic Breathing

If I could give any person with pelvic floor problems a single exercise to do, it would be this. The breath is SO powerful, and sync’d with the pelvic floor. For diaphragmatic breathing, you want your breath to move into your belly, expand your ribcage in all directions, then lift your chest. A misconception of diaphragmatic breathing is that the chest should not move at all, and this is FALSE. The chest should lift–but–so should the ribcage and the abdomen. You can do this in sitting or lying down. As you inhale, aim to lengthen and relax your pelvic floor muscles, then exhale, allowing your muscles to return to baseline. Start your sequence with 2-5 minutes of this breathing. (and toss in some focused relaxation of each part of your body while you’re doing it!)

Happy Baby or “the Frog”

This one is a key movement for anyone with pelvic pain! To perform this, lie on your back and bring your knees up to your chest. Reach your arms through your legs to grab your lower shins, support your legs using your arms, and allow your knees to drop open. You can alternatively hold your legs at your thighs, depending on your comfort and your hip mobility. From here, aim to let go of muscle tension. Then, take slow breaths, directing your breath to lengthen and open your pelvic floor muscles. This is a great position for relaxation and lengthening of the pelvic floor!

Segmental Bridge

This is a nice movement to warm up your spine and practice using small amounts of tension to perform a graded movement (you know I love my slow movements!) For this exercise, you will lie on your back with your knees bent. Then inhale in to prepare, exhale and slowly begin to roll up off the mat, lifting your tailbone, then sacrum, then low back, then mid back, then shoulder area. At the end of your exhale, slowly inhale, reversing the movement. You can repeat this 5-15 times, and do 1-3 sets. (Vary this based on what feels healthy and helpful to you!). Sometimes people get back pain when they do this (usually their back muscles are trying to do the job of the glutes). So, if this happens, try to bring your feet closer to your buttocks, and press through your feet while you are lifting. If it still happens, stop the exercise, and talk to your physical therapist.

Reach and Roll

I love this exercise for improving mobility of the upper back (thoracic spine). For this exercise, lie on your side with your knees and hips bent to 90 degrees, arms stacked in front of you at shoulder level. Inhale, reaching your top arm forward, exhale, and slowly roll your hand across your chest, opening to the opposite side. Keep your hips stacked so you don’t rotate through your low back. Pause here and inhale in, letting your ribcage expand, then exhale letting the hand glide across your chest to meet the opposite hand again. Repeat this movement 5-10 times on each side (You can do a few sets if you would like!)

Cat-Cow

So, this is another one of my top exercises. I love the cat-cow as it promotes segmental mobility of the lumbar and thoracic spine into flexion and extension. It is another great movement to encourage minimal tension, and coordination of breath, so it’s a big favorite for people with pelvic pain. To do this, get into a quadruped position (hands and knees, with hands aligned under shoulder and knees aligned under hips) Inhale, allowing your tailbone to come up and your back to dip down, head looking up. Exhale, dropping your head down, rolling your back up and tucking your tailbone. Perform this movements slowly, using small amounts of tension. Repeat this 10-15 times, 2 sets. You can alternate each set with child’s pose, listed below.

Child’s Pose (Wide-Kneed)

Child’s pose is a beautiful exercise that also encourages opening and lengthening of the pelvic floor muscles. It is nicely performed between sets of Cat-Cow. I like to modify this slightly by bringing the knees into a wide position to further encourage relaxation of the pelvic floor muscles. To perform this, begin in the quadruped (hands/knees) position as above. Open the knees into a wider position, keeping your feet together. Drop your pelvis back toward your feet, reaching your arms forward and relaxing down toward the mat. You can use a pillow (or 2 pillows!) to support your trunk and decrease how deep your child’s pose goes. Hold this position (and make sure you are totally comfortable!) for 60-90 seconds, breathing in long, slow breaths, encouraging lengthening and opening of your pelvic floor. Repeat this 2 times, preferably, interspersed with the Cat-Cow exercise.

And there you have it. My daily sequence for people with pelvic pain to get some movement in!

There are so many other great exercises for people with pelvic pain! Do you have any favorites I didn’t include in this sequence? Any movement challenges you want help solving? Let me know!

~ Jessica

How to build a stellar bowel routine

May 13, 2020 ~ jesspreale ~ Leave a comment

Bowel problems are so frustrating. Let’s be real. Constipation remains the #1 GI complaint in the country and impacts millions of people (pun unintended, but I’ll take it!). I love writing about pooping, and we love treating poop problems at Southern Pelvic Health (both virtually & in-person!!). The cool thing about poop, is that often the smallest changes in our habits can make BIG differences. A lot of this is due to the physiology of the digestive tract. Our habits—what we do during the day—can hugely impact this physiology, and that’s what I want to talk with you about today.

How do you maximize the efficiency of your digestive system and build a stellar bowel routine so you can poop better?

To understand this, let’s look at the digestive system a little more closely.

When you eat food, digestion begins in the mouth. Chewing helps to break up the food, and your saliva begins to break down the nutrients. Chewing alone is an essential part of digestion. In fact, most of us don’t tend to chew enough. I’ve been there! Years of working as a physical therapist at busy practices, led to a habit of inhaling my food rather than eating slowly and actually enjoying the process. Did you know that in order to adequately digest an almond, you have to chew that almond over 20 times? I learned that a few years ago when I interviewed Jessica Drummond- an incredible clinical nutritionist who also happens to be a pelvic PT. You can see the whole interview here if you’re interested!

After we swallow our food, the food travels down the esophagus into the stomach. Here, the stomach churns the food, mixing it with acid and juices and continues the process of digestion. When food enters the stomach, this triggers an important reflex called the gastrocolic reflex, which pushes prior meals and snacks through the rest of the digestive tract. This reflex is SUPER important to know to help stimulate regular movement in the GI system.

The food then exits the stomach and enters the small intestines. Did you know that if you uncoiled your small intestines, they would be 20 feet long? The intestines are where the majority of digestion occurs. Juices from the pancreas and gall bladder are added in here to aid in processing our nutrients. Food moves throughout these coils, then enters into the large intestine via the ileocecal valve.

The large intestine, or colon, is the major water recycling plant in the body. The colon recycles about 70% of the fluid we take in to use throughout the body. It continuously removes fluid from our stool…. So, what do you think happens if you don’t drink enough fluid? Or what do you think happens if your colon moves a little too slowly? Yep, that’s right. You end up with hard and dehydrated stool. When stool enters into the last part of the colon, the rectum, the stretching of the walls of the rectum trigger another reflex. First, an incredible reflex called the “sampling response” takes place. In this reflex, a small amount of contents are allowed to enter the anal canal. Your nerves here sense what is present, and tell your brain if the contents are liquid, gas or solid. (Amazing, right?!) Now, this reflex can sometimes be dysfunctional. So, if you struggle with feeling a strong need to poop, and when you get to the bathroom, it’s only gas? That’s this reflex. OR, if you feel like you have some gas to release, and when you release it, it’s actually a little bit of stool? That’s a sampling problem as well. And guess what—we can actually do things to retrain and improve this reflex.

As the stool is filling the rectum, and stretch occurs, the brain will receive the message of what is in the rectum, and gets to decide what to do about it. If there is just gas, you may choose to release it or wait a bit to release it. If it is liquid, your brain knows you better get to the bathroom QUICK! Liquid stool is hard to hold back for too long—the muscles fatigue—THIS is why chronic diarrhea can lead so often to bowel accidents! And if the stool is solid, you can actually defer and postpone the urge, until an appropriate time to go. The challenge there is that postponing frequently can make it so the muscular walls of the colon help you less when it is actually time to go to the bathroom.

When it is an appropriate time to go, you then sit on the toilet, relax your pelvic floor muscles, and this stimulates a defecation reflex which will allow the rectum to empty via the anal canal. Sometimes, we need to generate some pressure to assist this process, and sometimes, the muscular walls of the colon take care of it themselves.

So, let’s get down to it.

How do you use the process of digestion to build your bowel routine?

Step 1: Eat at regular intervals during the day to regularly stimulate your gastrocolic reflex.

Remember, this pushes things through the system, so it needs to happen often. The colon LOVES consistency, and HATES change. So, skipping meals? Eating really large meals sometimes, then nothing the rest of the day? All of this can impact your bowel function.

Step 2: Slow down & chew your meals.

Remember, chewing begins digestion, so, stop what you’re doing and eat mindfully and peacefully. Also, digestion requires a lot of parasympathetic activity—this is your resting & relaxing nervous system—so, slowing down and making time to eat can help stimulate that too.

Step 3: If you need the bowels to move better, eat “bowel stimulating” foods/drinks around the time of day you normally go to the bathroom.

What stimulates the bowels? Warm drinks (especially coffee—because the caffeine is actually an irritant to the GI tract!) are a great place to start. Also, spicy foods can help stimulate the GI system to move.

Step 4: Sit on the toilet around the same time each day, preferably, after a meal.

Remember that gastrocolic reflex? That reflex is helping to move things through the system, so after a meal is a great time to spend a few minutes relaxing on the toilet.

Step 5: Exercise!

Yep, exercise also stimulates the peristalsis of the GI tract! So, aim to get in regular bouts of exercise. And, it doesn’t need to be too extreme? Even going on a 10 minute walk can help get things moving.

What does this actually look like in practice? Here’s a sample routine!

Jane wakes up in the morning and takes the dogs on a short 10 minute walk. She gets home and makes a cup of coffee and her breakfast. She eats breakfast slowly, taking time to chew her food. (Jane also makes sure that she is getting plenty of fiber and whole fruits/veggies in her diet—because this matters too for her stool consistency!). After breakfast, Jane goes and sits on the toilet. She sits in a nice comfortable position, relaxes, breathes, and thinks about her day—spending 5 minutes without trying to force anything to happen. After a few minutes, she starts to feel the need to have a bowel movement. She uses what she learned in the “How to Poop” article, and gently pushes with good mechanics to assist her rectum in emptying her bowels. Jane then goes about her day, eating small amounts every few hours to stimulate her GI system.

Now, it’s your turn my friend! How is your bowel routine? What can you change to actually use your physiology and poop better?

Want more on pooping? Check out these articles:

How to Poop

Dyssynergic Defecation or When the Poop Won’t Come Out

Sex, Drugs…& No Poop?

Have a great rest of your week!

~ Jessica

Mother’s Day Specials!! My gift to YOU!

May 8, 2020May 8, 2020 ~ jesspreale ~ Leave a comment

Good morning friends,

With Mother’s Day around the corner, we’ve been wanting to give back and help out the mothers in our community (around the country…around the world!) who are struggling in this interesting new normal. Figuring out managing caring for children, homeschooling, work/family obligations, all while trying to keep their families safe, sane, engaged. Let’s be honest, being a mom is the hardest, but most rewarding job ever!

To celebrate our mamas everywhere, we have a few discounted specials to roll out to you!

50% off first Virtual Pelvic Floor Consultation

First, we are offering 50% off a virtual pelvic health consultation with one of our incredible pelvic floor specialists. Honestly, we’ve never discounted our services before, but I just felt like this was the right thing to do. So, for $97 you (or the mama you gift this to!) can receive a 55-minute virtual consultation. If you live in Georgia, this will be a pelvic floor physical therapy evaluation. If you don’t, our license won’t let us provide you with physical therapy, but we can still offer you a virtual coaching consultation. So, if you’re struggling with any pelvic health problem– constipation? pain with sex? bladder leaks?– or if you need help recovering after children, getting back to exercise, or preventing problems in the future– this deal is perfect for you! Don’t miss out on this opportunity!!

20% Off Online Classes

Along with this, we are offering 20% off our on-demand classes via the Southern Pelvic Health x The Vagina Whisperer partnership! Each of these classes is 90-minutes and covers SO much information, with great bonuses included! Classes are normally $39 each, so this is a nice discount to get some solid information!! (Gift idea: Consider a birth package for that pregnant mama in your life! Combine our birth prep class with a posptartum recovery class so that new mom has all she needs to rock her birth and after!) Be sure to use promo code MOM20 at checkout!

These specials are only available through Monday May 11, so don’t delay!

Happy Mother’s Day!

~Jessica

Diastasis Rectus Abdominis (Part 2): How can you help it?

April 30, 2020April 30, 2020 ~ jesspreale ~ 2 Comments

2 weeks ago, we chatted about what exactly is a diastasis rectus abdominus (DRA) and how to check to see if you have one. Today, we’re going to talk about how pelvic floor physical therapists evaluate a person with DRA, and what can be done to improve this. If you are struggling with support at your belly, I also hope you will join us for our upcoming LIVE class focused on this exact topic! Sara Reardon and I invited Sarah Duvall, an incredible expert, to join us for a 90-minute class on Diastasis Recti Rehabilitation. We took a lot of time to plan out this content, and I have to tell you all– this class is going to rock! The LIVE event is coming up Sunday May 3rd at 3pm EST, and it will be available after as a recording. We have a lot of great bonuses also– including handouts on exercises to get started and a lot more! Registration for the LIVE class is limited, so don’t wait to sign-up!

As we discussed previously, DRA involves an increased gap between the two bellies of the rectus abdominis muscle and a loss of support at the abdomen. Often times, people experiencing this will feel like they don’t have as much control or stability at their belly, and they may feel a bulging at their belly (some will even feel like they look pregnant when they aren’t!) We also discussed how to check to see if you do have a DRA. Now, let’s talk about how we approach making this better.

Your first visit

When we first evaluate someone with a DRA, we always make sure we get a complete history of the problems and challenges they are experiencing. This includes discussing any pregnancies/births (if applicable), their pelvic health (yep– bladder, bowel and sexual function), musculoskeletal challenges, medical problems, and their fitness preferences and routines. Then, we discuss their diastasis and what is bothersome to them. Is it primarily the appearance or the knowledge that it is there? Are they also struggling with back pain or pelvic organ prolapse or other problems? Does their diastasis limit their ability to exercise or lift their children? Our goal here is to really have a complete picture on the challenges they are facing.

The exam

Next, we move into an examination. This can include many different parts. As a diastasis is a pressure system problem, we want to look at everything that could impact the system. This could include:

Movement patterns
Spinal mobility
Preferred postures/positions
Ribcage movement
Breathing patterns
Pelvic floor function (yep, sometimes people with DRA benefit significantly from a specific pelvic floor exam if they’re on board with it!)
Scar tissue mobility
Myofascial mobility at the abdomen and the back
Abdominal, hip, and pelvic motor control/strength

Each of these components can actually influence how much pressure is at the linea alba (between the two bellies of the rectus abdominis) and the control at the abdomen. If someone has decreased movement around their spine and ribcage, this can impact the fascia around the abdomen and contribute to widening at their midline. If they have less optimal breathing patterns, this could be funneling pressure where we don’t want it to go, instead of spreading the pressure out across the trunk and sharing the load.

Once we do a comprehensive evaluation, we develop a treatment plan to address the problems we found. This typically includes:

Improving global movement patterns
Improving breathing patterns (both in static postures and during movements/activities)
Restoring mobility and improving sensitivity at muscles and soft tissues (including scars)
Optimizing the pressure system
Retraining the abdominal wall

I want to talk a little bit more about how we can optimize the pressure system and retrain the abdominal wall.

Optimizing the pressure system

When improving DRA, it’s very important to keep the pressure system in mind. Pressure at the abdomen and pelvis depends on coordination of several muscles that work together in synergy. This includes the glottis, intercostal muscles, respiratory diaphragm, transverse abdominis, lumbar multifidis and the pelvic floor muscles. Mary Massery (who has contributed SO much to our understanding of these pieces) created an analogy of a soda pop can.

In this analogy, the glottal folds are at the top, the pelvic floor muscles at the bottom, and the respiratory diaphragm in the middle. The intercostals, lumbar multifidus, and transverse abdominis are around the can. So, basically, these structures together work together to keep pressure spread out, leading to a strong and functional core. In the soda pop can example, the thin aluminum is pressurized on all sides, leading to a strong can that is difficult to break (Of course, this changes if the can is open or has a hole in it!)

So, in the case of a diastasis rectus, the pressure system is often not working optimally. Basically, pressure in many cases is funneled toward the belly, instead of being spread to all the structures, and this can contribute to gapping, bulging and a loss of support.

So, from a treatment standpoint, our goal becomes to optimize this system. We get to play detective and find out which of these structures are working well, and which need some assistance to do their job optimally. Then, we retrain this system, focusing on the natural synergy that should be present. When this is done well, we help the body learn to spread the load, decrease the funneling of pressure to the belly (or elsewhere) and thus, we improve what the person is experiencing at their abdomen.

Retraining the abdominal wall

After we improve the pressure system, we need to retrain all of the muscles in the abdominal wall. This further helps to improve the pressure system, but it also can assist in stimulating the fascia in the abdomen. Often times, retraining the abdomen starts by building the pressure system base like we discussed up above. This base– the pelvic floor- diaphragm- transverse abdominis- lumbar multifidus- base– is the key to what else we need to do to improve function at the abdomen. The transverse abdominis is particularly important. This muscle helps to tension the linea alba, which improves force transfer through this structure.

Next, we use breathing and awareness of muscles to retrain these muscles in a variety of movements, postures, and exercises. This can start as a simple progression– learning to activate these muscles while breathing and lifting an arm, then lifting a leg– and progressing from there.

We also teach self-awareness of the abdomen. So, this helps you identify how you manage pressure in your abdomen, and this is very important in making sure you are challenging your system, while still being able to control pressure (and not allow the pressure to funnel in your belly and produce coning and doming). As we progress in exercises, we ultimately want to retrain this system within the rest of the muscles in the abdomen, and this is fun, because we can be very creative and often help people progress toward things they did not think would be possible for them. So, can someone struggling with a diastasis eventually do planks? sit-ups? Abdominal crunches? What about pilates? Yoga? Barre classes? Most of the time, we can work together to help you reach the goals you want to reach. I really believe there are not “bad” exercises, but the key thing is determining the readiness of the person to do the exercise well, and ensuring that they can modulate pressure while doing the movement.

So, if you’re struggling with your belly…

Know, that there is hope. There is so much we can do to help restore stability at the abdomen and improve the way you move and transfer force through your belly. Come and join our upcoming class (or get the on-demand recording if you’re reading this later!) If you’re struggling, there can really be so much value to being evaluated by a pelvic health provider in person. So reach out! And if you need help finding a pelvic PT, check out this prior blog post to help you!

As always, reach out if you have questions!

~ Jessica

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